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Effects of stresses associated with extremely preterm birth may be biologically “recorded” in the genomes of individuals born preterm via changes in DNA methylation (DNAm) patterns. Genome-wide DNAm profiles were examined in buccal epithelial cells from 45 adults born at extremely low birth weight (ELBW; ≤1000 g) in the oldest known cohort of prospectively followed ELBW survivors (Mage = 32.35 years, 17 male), and 47 normal birth weight (NBW; ≥2500 g) control adults (Mage = 32.43 years, 20 male). Sex differences in DNAm profiles were found in both birth weight groups, but they were greatly enhanced in the ELBW group (77,895 loci) versus the NBW group (3,424 loci), suggesting synergistic effects of extreme prenatal adversity and sex on adult DNAm profiles. In men, DNAm profiles differed by birth weight group at 1,354 loci on 694 unique genes. Only two loci on two genes distinguished between ELBW and NBW women. Gene ontology (GO) and network analyses indicated that loci differentiating between ELBW and NBW men were abundant in genes within biological pathways related to neuronal development, synaptic transportation, metabolic regulation, and cellular regulation. Findings suggest increased sensitivity of males to long-term epigenetic effects of extremely preterm birth. Group differences are discussed in relation to particular gene functions.
To examine cross-sectional associations of four aspects of the consumer food environment – price, availability, marketing and product placement – with BMI and fruit and vegetable intake.
This cross-sectional study measured the consumer food environment using grocery store audits and surveys. Outcomes were measured through surveys and physical exams. Multivariable linear regression models were run; models were all adjusted for age, neighbourhood, education, race/ethnicity and financial burden.
Non-proportional quota sample of four socio-economically and racial/ethnically diverse neighbourhoods in Chicago, IL.
Women (n 228) aged 18–44 years.
Participants who reported seeing healthy food marketing had a higher vegetable intake (β = 0·24, 95 % CI 0·06, 0·42). There was some suggestive evidence that participants who shopped at stores that were more expensive (β = −0·90, 95 % CI −1·94, 0·14) had lower BMI, but this association was not statistically significant. Multivariable regression models did not indicate any significant association between any measure of the consumer food environment and fruit intake.
Our findings add to the growing interest in the role of the consumer food environment in health behaviours. Further research is needed to better understand the role of price and marketing characteristics on eating behaviours and BMI.
Introduction: Mastery learning, which deconstructs a complex task into sequential sub-steps combined with deliberate practice to achieve each step in sequence, represents an important method to enhance simulation-based procedural skills training. However, the evidence to support the effectiveness of this theory to improve learning is lacking. This study compared mastery learning using deliberate practice with self-guided practice on skill performance of a rarely performed, life-saving procedure, a bougie-assisted cricothyroidotomy (BAC). Methods: In this multi-centre, randomized study at five North American emergency medicine (EM) residency training programs, we assigned 166 EM postgraduate trainees to either mastery learning and deliberate practice (ML + DP) or self-guided practice for BAC. Three blinded airway experts independently evaluated BAC skill performance by video review before (pre-test) and after (post-test) each training session. The primary outcome was post-test skill performance using a 5-point global rating score (GRS). A secondary outcome, defined a priori, was performance time to complete the BAC skill (chronometry). Results: There was no significant difference in post-test BAC performance after ML + DP or self-guided practice. Performance scores improved for both groups by 13% from the pre-test to post-test (F (1,138) = 43, p < 0.001). Overall, time to complete the BAC improved significantly from pre-test (87.6 seconds) to posttest (54.1 seconds), (F, 1,149) = 122, p < 0.001). At post-test, the ML + DP group performed the skill 7.4 seconds faster than the self-guided practice group (F (1,150) = 6.77, p < 0.01). Conclusion: Mastery learning coupled with deliberate practice provides systematic and focused feedback during skill acquisition. However, it is resource intensive and its efficacy is not fully defined. In this study, MP + DP did not result in improved global performance; it did result in faster performance times, a relevant finding for time-sensitive procedures. These results are important for educators who seek to optimize technical skills training in a competency-based model of medical education. Our findings suggest that time-sensitive procedures might benefit from ML + DP teaching strategies to enhance time to procedural performance.
Audits play a critical role in maintaining the integrity of observational cohort data. While previous work has validated the audit process, sending trained auditors to sites (“travel-audits”) can be costly. We investigate the efficacy of training sites to conduct “self-audits.”
In 2017, eight research groups in the Caribbean, Central, and South America network for HIV Epidemiology each audited a subset of their patient records randomly selected by the data coordinating center at Vanderbilt. Designated investigators at each site compared abstracted research data to the original clinical source documents and captured audit findings electronically. Additionally, two Vanderbilt investigators performed on-site travel-audits at three randomly selected sites (one adult and two pediatric) in late summer 2017.
Self- and travel-auditors, respectively, reported that 93% and 92% of 8919 data entries, captured across 28 unique clinical variables on 65 patients, were entered correctly. Across all entries, 8409 (94%) received the same assessment from self- and travel-auditors (7988 correct and 421 incorrect). Of 421 entries mutually assessed as “incorrect,” 304 (82%) were corrected by both self- and travel-auditors and 250 of these (72%) received the same corrections. Reason for changing antiretroviral therapy (ART) regimen, ART end date, viral load value, CD4%, and HIV diagnosis date had the most mismatched corrections.
With similar overall error rates, findings suggest that data audits conducted by trained local investigators could provide an alternative to on-site audits by external auditors to ensure continued data quality. However, discrepancies observed between corrections illustrate challenges in determining correct values even with audits.
Introduction: Emergency physicians (EP) are expected to be competent in a variety of uncommon but life-saving procedures, including the bougie assisted cricothyrotomy (BAC). Given the rarity and high-stakes nature of the BAC, simulation is often used as the primary learning and training modality. However, mental practice (MP), defined as the “cognitive rehearsal of a skill in the absence of overt physical movement”, has been shown to be as effective as physical practice in several areas, including athletics, music, team-based resuscitation and surgical skill acquisition. MP scripts incorporate cues from different sensory modalities to supplement instructions of how to complete the skill. We sought to explore EPs perspectives on the kinesthetic, visual and cognitive aspects of performing a BAC to inform the development of a MP BAC script. Methods: We undertook a qualitative interview study of EPs at a single tertiary care centre who had done a BAC in clinical practice. Participants were recruited using purposive sampling. The primary method for data collection was in-depth semi-structured qualitative interviews, which were recorded and transcribed verbatim. Data collection and analysis were concurrent; transcripts were coded independently by two researchers using qualitative content analysis on a coding framework based on the previously developed BAC checklist. At each procedural step, the kinesthetic, visual and cognitive cues that enhance MP were identified. Results: Eight EPs (5 staff; 3 Royal College residents) participated in the interviews. All participants had completed at least one BAC in their clinical practice. Data analysis revealed recurrent themes signifying successful completion of each procedural step. These include visual (ie. seeing a spray of blood upon entry into the airway) and kinesthetic (ie. feel of the tracheal rings on a finger) cues that describe aspects of the procedure not found in traditional teaching modalities, such as textbooks. Conclusion: Knowledge gleaned from the interviews of EPs with lived experience gives us a deeper insight into the sensory aspects of performing a BAC in clinical practice. We expect that using these experientially derived cues to inform the development of a MP script will increase its validity and applicability to learners and for skill maintenance. Future work includes evaluating the utility of the developed script in acquiring and maintaining competence performing the BAC.
We aimed to quantify the proportion of people receiving care for HIV-infection that are 50 years or older (older HIV patients) in Latin America and the Caribbean between 2000 and 2015 and to estimate the contribution to the growth of this population of people enrolled before (<50yo) and after 50 years old (yo) (⩾50yo). We used a series of repeated, cross-sectional measurements over time in the Caribbean, Central and South American network (CCASAnet) cohort. We estimated the percentage of patients retained in care each year that were older HIV patients. For every calendar year, we divided patients into two groups: those who enrolled before age 50 and after age 50. We used logistic regression models to estimate the change in the proportion of older HIV patients between 2000 and 2015. The percentage of CCASAnet HIV patients over 50 years had a threefold increase (8% to 24%) between 2000 and 2015. Most of the growth of this population can be explained by the increasing proportion of people that enrolled before 50 years and aged in care. These changes will impact needs of care for people living with HIV, due to multiple comorbidities and high risk of disability associated with aging.
Introduction: Patient-reported outcome measures (PROM) are questionnaires that can be used to elicit care outcome information from patients. We sought to develop and validate the first PROM for adult patients without a primary mental health or addictions presentation receiving emergency department (ED) care and who were not hospitalized. Methods: PROM development used a multi-phase process based on national and international guidance (FDA, NQF, ISPOR). Phase 1: ED outcome conceptual framework qualitative interviews with ED patients post-discharge informed four core domains (previously published). Phase 2: Item generation scoping review of the literature and existing instruments identified candidate questions relevant for each domain for inclusion in tool. Phase 3: Cognitive debriefing existing and newly written questions were tested with ED patients post-discharge for comprehension and wording preference. Phase 4: Field and validity testing revised tool pilot tested on a national online survey panel and then again at 2 weeks (test-retest). Phase 5: Final item reduction using a Delphi process involving ED clinicians, researchers, patients and system administrators. Phase 6: Validation - psychometric testing of PROM-ED 1.0. Results: Four core outcome domains were defined in Phase 1: (1) understanding; (2) symptom relief; (3) reassurance and (4) having a plan. The domains informed a review of existing relevant questionnaires and instruments and the writing of additional questions creating an initial long-form questionnaire. Eight patients participated in cognitive debriefing of the long-form questionnaire. Expert clinicians, researchers and patient partners provided input on item refinement and reduction. Four hundred forty-four patients completed a second version of the long-form questionnaire (add in retest numbers) which informed the final item reduction process by a modified Delphi method involving 21 diverse contributors. The questionnaire was validated and underwent final revisions to create the 21 questions that constitute PROM-ED 1.0. Conclusion: Using accepted PROM instrument development methodology, we developed the first outcome questionnaire for use with adult ED patients who are not hospitalized. This questionnaire can be used to systematically gather patient-reported outcome information that could support and inform improvement work in ED care.
Introduction: Hospital shootings are rare events that pose extreme and immediate risk to staff, patients and visitors. In 2015, the Ontario Hospital Association mandated all hospitals devise an armed assailant Code Silver protocol, an alert issued to mitigate risk and manage casualties. We describe the design and implementation of ASSIST (Active Shooter Simulation In-Situ Training), an institutional, full-scale hybrid simulation exercise to test hospital-wide response and readiness for an active shooter event, and identify latent safety threats (LSTs) related to the high-stakes alert and transport of internal trauma patients. Methods: A hospital-wide in-situ simulation was conducted at a Level 1 trauma centre in downtown Toronto. The two-hour exercise tested a draft Code Silver policy created by the hospital’s disaster planning committee, to identify missing elements and challenges with protocol implementation. The scenario consisted of a shooting during a hospital meeting with three casualties: a manikin with life-threatening head and abdomen gunshot wounds (GSWs), a standardized patient (SP) with hypotension from an abdominal GSW, and a second SP with minor injuries and significant psychological distress. The exercise piloted the use of a novel emergency department (ED)-based medical exfiltration team to transport internal victims to the trauma bay. The on-call trauma team provided medical care. Ethnographic observation of response by municipal police, hospital security, logistics and medical personnel was completed. LSTs were evaluated and categorized using video framework analysis. Feasibility was measured through debriefings and impact on ED workflow. Results: Seventy-six multidisciplinary medical and logistical staff and learners participated in this exercise. Using a framework analysis, the following LSTs were identified: 1) Significant communication difficulties within the shooting area, 2) Safe access and transport for internal casualties, 3) Difficulty accessing hospital resources (blood bank) 4) Challenges coordinating response with external agencies (police, EMS) and 5) Delay in setting up an off-site command centre. Conclusion: In situ simulation represents a novel approach to the development of Code Silver alert processes. Findings from ethnographic observations and a video-based analysis form a framework to address safety, logistical and medical response considerations.
Introduction: Effective trauma resuscitation requires a coordinated team approach, yet there is a significant risk for error. These errors can manifest from sequential system-, team- and knowledge based failures, defined as latent safety threats (LSTs). In situ simulation (ISS), a point-of-care training strategy, provides a novel prospective approach to identify factors that impact patient safety. This study quantified and formulated a hierarchy of LSTs during risk-informed ISS trauma resuscitations. Methods: At a Level 1 trauma centre, we conducted 12 multi-disciplinary, unannounced ISSs to prospectively identify trauma-related LSTs. Four, risk-informed scenarios were developed based on 5 recurring themes found within the trauma program’s morbidity and mortality process. The actual, on-call trauma team participated in the study. Simulations were video recorded with 4 cameras, each positioned at a different angle. Using a framework analysis methodology, human factors experts transcribed and coded the videos. Thematic structure was established deductively based on existing literature and inductively based on observed ISS events. All LSTs were prioritized for future patient safety, systems and ergonomic interventions using the Healthcare Failure Mode and Effect Analysis (HFMEA) matrix. Results: We identified 893 LSTs from 12 simulations. LST analysis resulted in 8 themes subcategorized into 43 codes. Themes were associated with team-, knowledge- or system-related issues. The following themes emerged: situational awareness, provider safety, mental model alignment, team/individual responsibility, team resources, equipment considerations, workplace environment and clinical protocols. The HFMEA hazard scoring process identified 13 high priority codes that required urgent attention and intervention to mitigate negative patient outcomes. Conclusion: A prospective, video-based framework analysis represents a novel and robust approach to LST identification within trauma care. Patterns of LSTs within and between simulations provide a high degree of transparency and traceability for an inter-professional trauma program review. Hazard matrix scoring facilitates the classification and prioritization of human factors interventions intended to improve patient safety.
Introduction: There is strong evidence that socio-economic factors such as income, housing and ethnicity are linked to health outcome disparities for emergency department (ED) patients. However, lack of real-time patient data has limited our ability to identify, understand and address health disparities. During a 14-week period, we assessed the feasibility and acceptability of the systematic collection of patient-level equity data in a busy tertiary care urban ED. Methods: We assessed feasibility by directly observing impact on registration time, percentage of patients on which data was collected, and ambulance patient data collection. We also assessed acceptability to patients, registration staff and clinicians through structured interviews of patients systematically sampled, focus group and surveys of registration staff and survey of clinicians. Results: Over the course of the study, equity data was collected on 2017 patients. Capture rate peaked in week 7 with 51% of eligible patients offered the equity questions and 30% answering. Average patient registration time increased from 215 seconds to 345 seconds (60%). Data collection with ambulance patients did not appear feasible. Patients (n=30) reported being comfortable with most questions except income (47% comfortable). 93% believed it could improve health services. However, a small number of patients voiced concern that the data could result in discrimination. Registration staff required sustained support and engagement, but some continued to feel uncomfortable with offering the questionnaire to some patients. Conclusion: Large scale collection of equity data is feasible but requires additional resources and sustained staff and patient support. Patient participation rate is likely to remain relatively low and is likely to underestimate disadvantaged groups. Data collection at multiple points within an institution may improve capture rate.
Introduction: A cricothyroidotomy is a life-saving procedure and essential skill for EM physicians. The bougie-assisted cricothyroidotomy (BAC) is a newly describe technique that is both simple and reliable. There remains no consensus for the essential steps and ideal training strategy for the procedure. Using a modified Delphi process, we created an expert-derived checklist as a transferable educational tool for BAC instruction. Methods: A literature search was conducted to identify relevant articles describing the steps for BAC performance. These steps formed the first-iteration checklist for the modified Delphi process. Fourteen experts from general surgery, emergency medicine, otolaryngology, and anesthesia were recruited as participants for the Delphi process which consisted of three iterations. In the first two rounds, experts ranked each checklist step on a scale of 1-7, suggested additions, and provided comments. After each round the comments and rankings were integrated and steps with an average ranking of ≤3.0 were removed from the checklist for the next round. In the final round, consensus was sought by asking experts to indicate if this checklist was acceptable for teaching BAC to a novice learner. Results: A 22-item checklist was developed from a literature review. Following a modified Delphi methodology, the final BAC checklist contained 17 items. Internal consistency of the checklist was very good (α=0.855). In the third and final round, 86% of the participants agreed that the final iteration of the checklist. There was disagreement regarding “bougie hold up” as an appropriate method to confirm bougie position within the tracheal lumen. The checklist was modified, replacing “hold up” with digital palpation in the trachea as confirmation of successful bougie placement. With these modifications, consensus was achieved. Conclusion: Using a modified Delphi process, derived from existing literature and expert opinion, a 17-item BAC checklist was developed for novice instruction. This BAC checklist represents the first consensus-based set of steps for the procedure which may serve as a useful tool for trainee instruction and evaluation. Future research is required to test the validity of this checklist in training for a BAC and its applicability within competency-based medical education.
Introduction: Resuscitation of a trauma patient requires a multidisciplinary team to perform in a dynamic, high-stakes environment. Error is ubiquitous in trauma care, often related to latent safety threats (LSTs) - previously unrecognized threats that can materialize at any time. In-situ simulation (ISS) allows a team to practice in their authentic environment while providing an opportunistic milieu to explore critical events and uncover LSTs that impact patient safety. Methods: At a Canadian Level 1 trauma centre, regular, unannounced trauma ISSs were conducted and video-recorded. A retrospective chart review of adverse events or unexpected deaths informed ISS scenario design. Each session began with a trauma team activation. The on-duty trauma team arrived in the trauma bay and provided care as they would for a real patient. Semi-structured debriefing with participant-driven LST identification and ethnographic observation occurred in real time. A framework analysis using video review was conducted by human factors experts to identify and evaluate LSTs. Feasibility was measured by the impact on ED workflow, interruptions of clinical care and participant feedback. Results: Six multidisciplinary, high-fidelity, ISS sessions were conducted and 70 multidisciplinary staff and trainees participated in at least one session. Using a framework analysis, LSTs were identified and categorized into seven themes that relate to clinical tasks, equipment, team communication, and participant workflow. LSTs were quantified and prioritized using a hazard scoring matrix. ISS was effectively implemented during both low and high patient volume situations. No critical interruptions in patient care were identified during ISS sessions and overall participant feedback was positive. Conclusion: This novel, multidisciplinary ISS trauma training program integrated risk-informed simulation cases with human factors analysis to identify LSTs. ISS offers an opportunity for an iterative review process of high-risk situations beyond the traditional morbidity and mortality rounds; rather than waiting for an actual case to generate discussion and review, we prophylactically examined critical situations and processes. Findings form a framework for recommendations about improvements in equipment, environment layout, workflow, system processes, effective team training, and ultimately patient safety.
Introduction / Innovation Concept: Trauma resuscitation requires a multidisciplinary team to perform at a high level within a dynamic, high-stakes environment. The unpredictable nature of trauma care increases the possibility for errors, often from underlying latent safety threats (LSTs). In-situ simulation (ISS) is a point-of-care training strategy that occurs within the patient care environment involving the actual healthcare team and provides a novel approach to team training and LST identification. Using ISS, critical events can be recreated providing an opportunity to explore and learn from past challenges. We developed and piloted a risk-informed, multidisciplinary ISS trauma training program to assess teamwork performance and identify LSTs within the trauma care environment. Methods: A comprehensive process was initiated to gain support from all stakeholders within the trauma program. Simulation cases were derived from a review of adverse events and unexpected deaths. Human factors experts aided with the integration of system- and process-related elements into the case design. ISS sessions involved all trauma team members. Debriefing after each session facilitated a team-based discussion and an opportunity for reflective practice and video recording was used for teamwork evaluation and process mapping. Curriculum, Tool, or Material: We conducted monthly, unannounced, multidisciplinary, high-fidelity ISS scenarios at a Canadian Level 1 trauma centre. The trauma team was activated by the usual notification process and care provided in the same manner as an actual trauma patient. A semi-structured debriefing followed each session with a focus on team performance and LST identification. Teamwork was measured using a previously validated tool, the Clinical Teamwork Scale. Findings were used to inform discussion at multidisciplinary trauma rounds as part of an iterative process of evaluation and implementation. Conclusion: This multidisciplinary ISS trauma training program offers a novel approach to team performance evaluation and LST identification. Using risk-informed scenarios combined with human factors analysis we are able identify knowledge and technical skill proficiency gaps, LSTs and integrate formative team assessment. An iterative process beginning with ISS followed by multidisciplinary rounds provides a robust framework for system-based changes to improve team performance and overall patient care.
Introduction: Any large-scale disaster may place a hospital system in a precarious position. Planning is fundamental to facilitate an equitable process for allocating scarce critical care resources, yet there is a paucity of literature guiding protocol development, and few Canadian hospitals have done this planning. We performed a scoping review of the available literature, and used this data to develop a hospital-wide policy to guide critical care resource allocation as part of the hospital emergency management planning process. Methods: A primary search of MEDLINE (1946-2015), EMBASE (1980-2015), Disaster Lit (2002-2010) and Pubmed focusing on a priori criteria was completed. A secondary search of the grey literature served to increase sensitivity and rigor. Two independent reviewers manually reviewed the citations, and selected eligible abstracts for full-text. Qualitative thematic analysis was undertaken of the selected articles. The results then informed the development of a hospital-wide policy and protocol to guide critical care resource allocation. Results: The search identified 832 citations; 134 papers were reviewed and 11 selected for qualitative analysis. All included papers were expert opinion and reviews. All suggested that an ethical framework be used; eight discussed this in detail. Ten recommended allocating a triage team to implement the protocol. Nine papers recommended specific resource allocation protocols with inclusion/exclusion criteria, physiologic scores, and reassessment at varying time intervals (12-120 hours). Conclusion: Effective planning, prior to a disaster, is critical to saving as many lives as possible. Based on our scoping review, we have developed a hospital-wide protocol that incorporates ethical principles and clear inclusion and exclusion criteria, to help avoid inequity and promote transparent decision-making. Next steps include a public consultation process and review, prior to implementation testing and educational roll-out.
Introduction: Diagnosing the undifferentiated dyspneic emergency department (ED) patient remains a challenge for clinicians; in order to rule in or out acute heart failure (AHF) natriuretic peptide biomarker testing has evolved and is recommended by cardiology international guidelines to be utilized in these presentations. However there is equipoise in the emergency community for its use, largely due to perceived modest test specificity. We sought to analyze this apparent clinical dichotomy as part of a multicenter trial of undifferentiated dyspneic ED patients. Methods: Patients with dyspnea presenting between October 2010 and October 2013 to one of four ED sites -2 Canadian, 1 American, 1 New Zealand- were assessed by certified staff emergency physicians (EPs) and their chest Xray reviewed. Those patients with undifferentiated dyspnea with a potential for AHF (ie further investigated or treated for AHF but investigated and/or treated for another cause) were consented and enrolled. Two of the sites (American, New Zealand) had NT-proBNP assay ordered as a standard of care for these patients; the other 2 sites did not. At the end of Emergency care, the EP recorded the primary diagnosis of the dypnea-either “AHF” or “Not AHF.” Blinded adjudication was carried out by 2 cardiologists after reviewing sequential records: first, with index ED records but no NT-proBNP result; second, with the NT-proBNP result and lastly, with follow up 60 day records (deemed the gold standard diagnosis). EP accuracy between NT-proBNP and no NT-proBNP sites and NT-proBNP accuracy using standard cutpoints were calculated, as were the number of adjudicated cases influenced by exposure to NT-proBNP. Results: 197 patients were enrolled, 107 at NTproBNP sites and 90 at the other 2 sites. EP accuracy was 76% for either site. NT-proBNP used as a binary test with recommended age-stratified cutoffs had 80% accuracy, applied to 70% of patients (30% remained in “gray zone”).Cardiology adjudicators reversed 16% of initial diagnoses upon exposure to NT-proBNP result, ultimately diagnosing 41% of patients with AHF. Conclusion: This study supports the clinical equipoise amongst emergency physicians compared to cardiologists for the use of NT-proBNP in diagnosing acute heart failure in the undifferentiated dyspneic Emergency patient.
The Critically Endangered Himalayan Quail Ophrysia superciliosa has not been reliably recorded since 1876. Recent searches of historical sites have failed to detect the species, but we estimate an extinction year of 2023 giving us reason to believe that the species may still be extant. Species distribution models can act as a guide for survey efforts, but the current land cover in the historical specimen record locations is unlikely to reflect Himalayan Quail habitat preferences due to extensive modifications. Thus, we investigate the use of two proxy species: Cheer Pheasant Catreus wallechi and Himalayan Monal Lophophorus impejanus that taken together are thought to have macro-habitat requirements that encapsulate those of the Himalayan Quail. After modelling climate and topography space for the Himalayan Quail and these proxy species we find the models for the proxy species have moderate overlap with that of the Himalayan Quail. Models improved with the incorporation of land cover data and when these were overlaid with the Himalayan Quail climate model, we were able to identify suitable areas to target surveys. Using a measure of search effort from recent observations of other galliformes, we identify 923 km2 of suitable habitat surrounding Mussoorie in Northern India that requires further surveys. We conclude with a list of five priority survey sites as a starting point.